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Vaginitis (Candidal)
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
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Bell's palsy
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Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
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Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
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Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
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Infectious mononucleosis
Influenza
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Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
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Tick-borne illness (Lyme disease)
Tinea infection
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Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Vaginitis (Candidal)
POCUS
Procedures
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ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Urgency assessment
▶
Vulvovaginal candidiasis (VVC) is rarely a life threat in isolation
▶
Severity classification drives management pathway
Immunocompromised state escalates urgency
Red flag features requiring urgent workup
▶
Fever and pelvic pain suggest PID or tubo-ovarian abscess
Cervical motion tenderness requires bimanual exam and broader evaluation
Severe vulvar edema with systemic signs suggests necrotizing infection or sepsis
If sepsis features present, initiate resuscitation immediately
▶
Broad-spectrum antibiotics within 1 hour
IV fluid resuscitation for hypotension
Monitoring and targets
Hemodynamic monitoring when systemically unwell
▶
Heart rate and blood pressure
▶
Tachycardia as sepsis marker
SBP < 90 mmHg triggers escalation
Temperature
▶
Fever argues against isolated VVC
Fever with pelvic tenderness mandates PID workup
Oxygen saturation when sepsis suspected
▶
SpO2 target >= 94%
Lactate if sepsis screen positive
Escalation triggers
Consultation and escalation indications
▶
Gynecology consult
▶
PID, tubo-ovarian abscess, or ectopic pregnancy suspected
Severe or necrotizing vulvovaginal infection
Immunocompromised host with refractory VVC
▶
HIV with low CD4 count
Chemotherapy or chronic immunosuppression
Pregnancy with complicated VVC
▶
First trimester with systemic features
Failed topical therapy requiring systemic management
History
Presenting symptoms
Cardinal symptoms of VVC
▶
Vulvovaginal pruritus
▶
Most common presenting symptom
Often severe and distressing
Vaginal discharge character
▶
White, thick, curd-like or cottage cheese consistency
Typically odorless distinguishes from bacterial vaginosis
Vulvar burning and irritation
▶
External dysuria from urethral or vulvar inflammation
Dyspareunia
Timing relative to menstrual cycle
▶
Premenstrual flare common
Onset relative to antibiotic use
Risk factors
Predisposing exposures
▶
Recent antibiotic use
▶
Most common modifiable risk factor
Broad-spectrum agents carry highest risk
Hormonal factors
▶
Pregnancy
High-estrogen oral contraceptives
Hormone replacement therapy
Uncontrolled diabetes mellitus
▶
Elevated glucose in vaginal secretions
Recurrent or refractory VVC as diabetes marker
Immunosuppression
▶
HIV infection especially CD4 < 200 cells/mcL
Systemic corticosteroids
Chemotherapy
Vaginal microbiome factors
▶
Douching disrupts protective Lactobacillus flora
Scented vaginal products
Intrauterine device use
Recurrence and severity classification
Recurrent VVC (RVVC) criteria
▶
Four or more symptomatic episodes in 12 months
▶
Drives extended maintenance therapy
Culture-confirmed diagnosis recommended before maintenance
Prior treatment history
▶
OTC vs prescription products
Azole response or failure
Complicated vs uncomplicated classification
▶
Complicated: severe, recurrent, non-albicans species, or immunocompromised host
Uncomplicated: mild-moderate, sporadic, C. albicans, immunocompetent host
Important negatives
Features arguing against VVC
▶
Malodor suggests bacterial vaginosis or trichomoniasis
Frothy or green-yellow discharge suggests trichomoniasis
Fever or pelvic pain argues against isolated VVC
Vesicles or ulcers suggest herpes simplex virus
Sexual history
▶
New sexual partner
Partner symptoms including balanitis
Sexually transmitted infection screen when indicated
Past medical history
Relevant medical history
▶
Prior VVC episodes and frequency
▶
Classify as uncomplicated vs recurrent
Treatments used and response
Diabetes mellitus type and glycemic control
HIV status and CD4 count if applicable
Chronic skin conditions
▶
Eczema or psoriasis may mimic or coexist
Lichen sclerosus or lichen planus
Recent medications
▶
Antibiotics within prior 4 to 8 weeks
Systemic steroids
Immunosuppressants
Physical Exam
Vitals and general
Vital sign assessment
▶
Temperature
▶
Fever argues against isolated VVC
Fever with pelvic pain mandates PID workup
Heart rate and blood pressure
▶
Tachycardia as severity or sepsis marker
Hemodynamic instability requires escalation
General appearance
▶
Severity of distress correlates with complexity
Systemic illness features require broader evaluation
External genitalia exam
Vulvar findings
▶
Erythema and edema of vulva and labia
▶
Marked edema and fissuring suggests severe or complicated VVC
Satellite lesions beyond main erythema zone
Excoriations from pruritus
Ulcers or vesicles
▶
Vesicles suggest herpes simplex virus
Ulcers require alternative diagnosis consideration
Architectural changes
▶
Lichen sclerosus: white atrophic plaques
Lichen planus: erosive or reticular pattern
Speculum and vaginal exam
Speculum findings
▶
Vaginal discharge character
▶
White, thick, adherent curd-like discharge typical of VVC
Thin homogenous discharge suggests bacterial vaginosis
Frothy discharge suggests trichomoniasis
Vaginal wall appearance
▶
Erythematous mucosa in VVC
Pale atrophic mucosa in atrophic vaginitis
Cervix appearance
▶
Mucopurulent cervical discharge suggests cervicitis or PID
Cervical motion tenderness on bimanual mandates further evaluation
Bimanual exam
Pelvic assessment
▶
Uterine tenderness
▶
Presence suggests PID or endometritis
Absence supports isolated vaginitis diagnosis
Adnexal assessment
▶
Adnexal tenderness suggests PID or ovarian pathology
Adnexal mass requires imaging
Cervical motion tenderness
▶
Sensitivity for PID approximately 95% but low specificity
Presence requires gonorrhea and chlamydia testing
PITFALLS
Diagnostic pitfalls
▶
Self-diagnosis accuracy is poor
▶
Only 35% of women self-diagnosing VVC are correct
OTC treatment without confirmation leads to delays in correct diagnosis
Polymicrobial infections
▶
VVC may coexist with bacterial vaginosis or trichomoniasis
Full wet mount and pH testing required
Misclassifying vulvar dermatoses as VVC
▶
Lichen sclerosus and contact dermatitis require different management
Persistent symptoms despite adequate antifungal therapy prompt biopsy consideration
Differential Diagnosis
Life threats and urgent diagnoses
Urgent diagnoses requiring exclusion
▶
Pelvic inflammatory disease
▶
ICD-10 N73.0 acute parametritis and pelvic cellulitis
Fever, bilateral lower abdominal pain, cervical motion tenderness
Tubo-ovarian abscess
▶
ICD-10 N70.93
Adnexal mass on exam or ultrasound
Ectopic pregnancy
▶
ICD-10 O00.9
Pelvic pain and missed period require urine hCG
Vulvar necrotizing fasciitis (Fournier gangrene)
▶
ICD-10 N76.89
Rapidly spreading erythema, crepitus, systemic toxicity
Surgical emergency requiring immediate consultation
Infectious mimics
Infectious vaginitis differential
▶
Bacterial vaginosis
▶
ICD-10 N76.0
Thin, gray-white, homogenous discharge with fishy odor
pH > 4.5 and clue cells on wet mount
Positive whiff test with KOH application
Trichomoniasis
▶
ICD-10 A59.01
Frothy, yellow-green discharge with vulvar irritation
pH > 4.5 and motile trichomonads on wet mount
Strawberry cervix on speculum exam
Herpes simplex vulvitis
▶
ICD-10 A60.0
Vesicles progressing to painful ulcers
Pain predominates over itch
Cervicitis (gonorrhea or chlamydia)
▶
ICD-10 N72
Mucopurulent cervical discharge
Predominantly cervical findings not vaginal
Non-infectious mimics
Non-infectious vulvovaginal conditions
▶
Contact or irritant dermatitis
▶
ICD-10 L25.3
Exposure to soaps, detergents, spermicides, or fabric softeners
No infectious organisms on microscopy or culture
Atrophic vaginitis
▶
ICD-10 N95.2
Postmenopausal or estrogen-deficient state
Pale, thin, dry vaginal mucosa with loss of rugae
Lichen sclerosus
▶
ICD-10 L90.0
Chronic white atrophic plaques on vulvar skin
Architectural distortion with labial fusion in severe cases
Desquamative inflammatory vaginitis
▶
ICD-10 N76.89
Purulent discharge, diffuse erythema, parabasal cells on wet mount
pH > 4.5 without BV or trichomonas identified
Psoriasis vulvaris
▶
ICD-10 L40.9
Chronic erythematous plaques without scale due to moisture
Other skin sites involvement clue
Laboratory Tests
Bedside testing
Point-of-care microscopy
▶
Vaginal pH
▶
Normal vaginal pH 4.0 to 4.5 in VVC
pH > 4.5 suggests bacterial vaginosis or trichomoniasis
Use pH paper or colorimetric test strip
Saline wet mount microscopy
▶
Evaluation for clue cells of bacterial vaginosis
Evaluation for motile trichomonads
Lactobacillus predominance in VVC
KOH preparation (10% KOH)
▶
Pseudohyphae and budding yeast cells diagnostic of VVC
Sensitivity approximately 50% compared to culture
Specificity high when positive
Whiff test with KOH
▶
Negative in VVC (no amine odor)
Positive result fishy odor suggests bacterial vaginosis
Confirmatory and culture testing
Vaginal yeast culture
▶
Gold standard for VVC diagnosis
▶
Allows species identification (C. albicans vs non-albicans)
Required for recurrent or treatment-refractory disease
Species-level identification guides therapy
▶
C. albicans responds to azoles in most cases
C. glabrata often azole-resistant
C. auris emerging resistant pathogen requiring special handling
Sensitivity and susceptibility testing
▶
Indicated for non-albicans species
Indicated for azole treatment failure
Molecular testing
NAAT and multiplex panels
▶
Multiplex vaginal PCR panels
▶
High sensitivity and specificity for BV, VVC, and trichomoniasis
Useful when microscopy is unavailable or equivocal
Not required for straightforward uncomplicated VVC
Performance characteristics
▶
Sensitivity superior to wet mount for all three conditions
Specificity remains high across platforms
Ancillary testing
Systemic evaluation when indicated
▶
Urine hCG
▶
Mandatory before fluconazole in reproductive-age women
Contraindication to fluconazole in pregnancy
Glucose and HbA1c
▶
Recurrent VVC as potential presentation of undiagnosed diabetes
Target HbA1c < 53 mmol/mol (7%) to reduce recurrence risk
HIV testing
▶
Risk factor-based testing for recurrent or refractory VVC
CD4 count if HIV-positive
STI screen (gonorrhea and chlamydia NAAT)
▶
When cervicitis or PID features present
Not routine for uncomplicated VVC
Diagnostic Tests
Scoring Systems
VVC classification systems
▶
Uncomplicated VVC criteria (all must be present)
▶
Mild to moderate severity
Sporadic or infrequent episodes
Presumed Candida albicans etiology
Non-immunocompromised host
Complicated VVC criteria (any one present)
▶
Severe signs including extensive vulvar erythema, edema, excoriation, or fissures
Four or more symptomatic episodes in 12 months (RVVC)
Non-albicans Candida species suspected or confirmed
Pregnancy
Uncontrolled diabetes, immunosuppression, or HIV infection
RVVC definition per IDSA and CDC guidelines
▶
Four or more mycologically confirmed episodes per year
Maintenance suppressive therapy required after induction
MRI
MRI pelvis role in vulvovaginal disease
▶
Not indicated for routine VVC evaluation
▶
Diagnosis established by clinical and microscopic criteria
Radiation-free alternative to CT when anatomic detail required
Indications in complex or refractory vulvovaginal disease
▶
Suspected Bartholin gland abscess with deep extension
Suspected necrotizing fasciitis extent mapping prior to surgery
Complex pelvic pathology when ultrasound is equivocal
MRI findings in complicated vulvar infections
▶
Fascial plane edema and gas in necrotizing fasciitis
Multiloculated fluid collections in deep abscesses
CT
CT pelvis role
▶
Not indicated for isolated VVC
▶
Clinical and microscopic diagnosis sufficient
Avoid radiation exposure without indication
CT indications when diagnosis is uncertain or complications suspected
▶
Tubo-ovarian abscess not visualized on ultrasound
Suspected necrotizing fasciitis extent
Alternative pelvic pathology requiring anatomic delineation
CT findings relevant to vulvovaginal pathology
▶
Gas within soft tissue planes in necrotizing infection
Complex adnexal mass characteristics
Free fluid in PID or ectopic rupture
Ultrasound
Pelvic ultrasound indications
▶
Not indicated for uncomplicated VVC
▶
Clinical and microscopic findings sufficient for diagnosis
Reserve for suspected complications
Transvaginal ultrasound for pelvic complications
▶
Tubo-ovarian abscess identification
▶
Multiloculated complex adnexal mass
Internal echoes with thick septations
Endometrial thickness and fluid assessment in PID
Ectopic pregnancy evaluation when hCG positive
Transabdominal ultrasound
▶
Upper limit of transvaginal views
Acute abdomen screen when PID or ruptured ectopic suspected
Bedside emergency department POCUS
▶
Free fluid in Morrison's pouch suggests significant pelvic pathology
Adnexal mass screen when clinical suspicion raised
Not a replacement for formal study when ectopic or TOA suspected
Disposition
Outpatient criteria
Discharge suitability for VVC
▶
Uncomplicated VVC without systemic features
▶
Hemodynamically stable without fever
No pelvic tenderness or adnexal findings
Diagnosis confirmed or clinically certain
Medication adherence and access confirmed
▶
Topical or oral antifungal prescription dispensed
Patient able to follow treatment course
Adequate follow-up plan
▶
Return precautions clearly communicated
Follow-up with primary care or gynecology within 1 to 4 weeks for recurrent cases
Admission indications
Criteria for admission or escalation
▶
PID with failure of outpatient therapy or inability to tolerate oral antibiotics
▶
Temperature >= 38.3 C
WBC > 11.0 x10(9)/L
Tubo-ovarian abscess identified
▶
Requires IV antibiotics and surgical planning
Admission mandatory
Necrotizing vulvar infection
▶
Immediate surgical consultation
ICU-level care often required
Immunocompromised patient with systemic fungal infection concern
▶
Candidemia or invasive candidiasis not excluded
Blood cultures and infectious disease consult
Follow-up planning
Copy
Outpatient follow-up recommendations
▶
Uncomplicated VVC
▶
No routine follow-up required if symptoms resolve
Return if symptoms persist beyond treatment completion or recur within 2 months
RVVC after induction therapy
▶
Follow-up at 1 to 2 months to confirm mycologic cure
Ongoing monitoring during 6-month maintenance course
Complicated VVC
▶
7 to 14 day follow-up to confirm response
Culture to confirm eradication before concluding therapy
Treatment
Uncomplicated VVC first-line therapy
Oral azole therapy
▶
Fluconazole 150 mg PO single dose
▶
Preferred by most patients for convenience
Clinical cure rate > 90%
Contraindicated in pregnancy
Drug interactions: warfarin, phenytoin, cyclosporine, QT-prolonging agents
Efficacy equivalent to topical azoles for uncomplicated VVC
▶
Class I recommendation for either oral or topical route
Patient preference guides route selection
Topical azole therapy
▶
Clotrimazole 1% cream or 100 mg vaginal tablet
▶
7-day course for cream
7-day course for vaginal tablet
Miconazole 2% cream or 100 mg vaginal suppository
▶
7-day course for cream
7-day course for suppository
Available OTC in many jurisdictions
Terconazole 0.4% or 0.8% cream
▶
7-day course for 0.4% cream
3-day course for 0.8% cream
Prescription required
Butoconazole 2% sustained-release cream
▶
Single 5 g intravaginal application
Bioadhesive formulation
Patient counseling for topical agents
▶
Oil-based formulations may weaken latex condoms and diaphragms
Complete full course even if symptoms improve early
Severe acute VVC treatment
Extended fluconazole dosing
▶
Fluconazole 150 mg PO every 72 hours for 2 to 3 doses
▶
IDSA recommendation for severe acute VVC
Based on severity score of extensive erythema, edema, or fissuring
Topical azole extended course alternative
▶
7 to 14 days of any topical azole agent
Preferred when fluconazole contraindicated
Recurrent VVC management
Induction phase
▶
Fluconazole 150 mg PO every 72 hours for 3 doses
▶
Days 1, 4, and 7 of induction
Achieves mycologic cure before maintenance phase
Topical azole induction alternative
▶
10 to 14 days of topical azole therapy
Culture to confirm clearance
Maintenance suppressive phase
▶
Fluconazole 150 mg PO once weekly for 6 months
▶
Reduces recurrence in approximately 90% during treatment
Recurrence risk returns after cessation
IDSA Class I recommendation
Monitoring during maintenance
▶
Hepatic function testing if prolonged course in patients with liver disease risk
Drug interaction review at initiation
Newer agents for RVVC
▶
Oteseconazole (Vivjoa)
▶
FDA-approved 2022 for RVVC
Oral capsule 150 mg daily for 14 days then 150 mg once weekly for 11 weeks
Contraindicated in women of reproductive potential due to teratogenicity
Not suitable for premenopausal women unless effective contraception confirmed
Ibrexafungerp (Brexafemme)
▶
FDA-approved for acute and recurrent VVC
300 mg PO twice daily for 1 day for acute VVC
300 mg PO twice daily for 1 day each month for 6 months for RVVC
Triterpenoid glucan synthase inhibitor with novel mechanism
Teratogenic — requires effective contraception during treatment and 4 days after
Non-albicans candidiasis treatment
C. glabrata (Nakaseomyces glabrata) management
▶
Intravaginal boric acid
▶
600 mg gelatin capsule intravaginally once daily for 14 days
Evidence level supports use for non-albicans or azole-refractory VVC
Toxic if ingested orally — patient education required
Not for use in pregnancy
Nystatin vaginal suppositories
▶
100,000 units daily for 14 days
Alternative when boric acid unavailable or refused
Flucytosine 5-FC cream compounded intravaginal
▶
17% cream 5 g nightly for 14 days
Combined with amphotericin B cream in refractory cases
Specialist referral for persistent non-albicans VVC
▶
Sensitivity testing to guide therapy
Infectious disease or gynecology input
Adjunctive measures
Non-pharmacologic support
▶
Symptom relief during treatment
▶
External hydrocortisone 1% cream short course for severe pruritus
Cool sitz baths for vulvar comfort
Glycemic optimization in diabetic patients
▶
Target HbA1c reduction reduces recurrence
Endocrine referral if diabetes poorly controlled
Avoid precipitating factors
▶
Discontinue or modify antibiotic courses when possible
Switch to lower-estrogen OCP or alternative contraception if hormonal trigger
Probiotics
▶
No evidence supports use for VVC treatment or prevention
IDSA does not recommend routine use
Special Populations
Pregnancy
VVC in pregnancy
▶
Prevalence increased to 30% in third trimester
▶
Elevated estrogen and glycogen promote Candida overgrowth
More frequent and more severe episodes common
Fluconazole contraindicated throughout pregnancy
▶
Associated with increased spontaneous abortion risk
Craniofacial and cardiac defects in first trimester animal data
FDA category X for fluconazole in pregnancy
Observational human data support spontaneous miscarriage risk
Safe treatments in pregnancy
▶
Topical azoles recommended for all trimesters
Clotrimazole 1% cream or 100 mg tablet 7-day course preferred
Miconazole 2% cream or 100 mg suppository 7-day course acceptable
Terconazole topical alternatives
Treatment duration in pregnancy
▶
7-day courses preferred over shorter courses
Higher mycologic cure rate with longer topical therapy in pregnancy
Oteseconazole and ibrexafungerp contraindicated in pregnancy
▶
Teratogenic risk in animal models
Boric acid contraindicated in pregnancy
Clinical implications
▶
Symptomatic treatment reduces maternal discomfort
No proven reduction in preterm birth with VVC treatment
Geriatric
VVC in older adults
▶
Atypical presentation
▶
Pruritus may be attributed to atrophic vaginitis
Overlapping conditions common
Estrogen deficiency interaction
▶
Atrophic vaginitis increases vaginal pH and susceptibility
Coexisting atrophic changes require concurrent management
Topical estrogen may restore protective Lactobacillus flora
Undiagnosed diabetes as underlying cause
▶
New or recurrent VVC in older adults warrants glucose screening
HbA1c testing appropriate
Drug interaction considerations
▶
Fluconazole interacts with anticoagulants, statins, and antiepileptics common in geriatric patients
Review complete medication list before prescribing
QT prolongation risk with fluconazole in patients on multiple QT-prolonging medications
Oteseconazole use
▶
Suitable for postmenopausal women with RVVC not of reproductive potential
Avoids QT interaction risk compared to fluconazole
Pediatrics
VVC in pediatric patients
▶
Prepubertal VVC
▶
Uncommon in prepubertal girls due to low estrogen environment
Consider diabetes, recent antibiotic use, or diaper dermatitis etiology
Sexual abuse evaluation when prepubertal vulvovaginitis recurring without clear cause
Adolescent VVC management
▶
Same diagnostic criteria as adults after menarche
Risk factors include antibiotic use, OCP initiation, sexual activity
Treatment in children
▶
Topical nystatin or clotrimazole for diaper-area candidiasis
Fluconazole 3 mg per kg per dose PO for invasive or systemic candidiasis in children
Standard adult fluconazole 150 mg single dose appropriate for adolescents of reproductive age with confirmed VVC
Candidal diaper dermatitis
▶
Satellite pustules and erythematous patches beyond diaper margin
Topical nystatin 100,000 units per g cream applied 3 to 4 times daily
Oral fluconazole if topical therapy fails or systemic concern
Background
Epidemiology
Burden and prevalence
▶
Second most common cause of infectious vaginitis
▶
Bacterial vaginosis is most common
Approximately 1.4 million outpatient visits annually in the United States
Lifetime prevalence
▶
Approximately 75% of women experience at least one episode before menopause
Approximately 40% to 45% experience two or more episodes
RVVC prevalence
▶
Approximately 5% to 8% of women in reproductive years
Significant impact on quality of life and healthcare utilization
Causative organism distribution
▶
Candida albicans responsible for approximately 85% to 90% of cases
Candida glabrata (Nakaseomyces glabrata) accounts for most remaining cases
Candida parapsilosis, C. tropicalis, C. krusei less common
Non-albicans species rising with azole use and immunosuppression
Pathophysiology
Candida colonization and infection mechanisms
▶
Normal vaginal carriage
▶
Candida colonizes vagina asymptomatically in 10% to 20% of women
Transition from colonization to infection involves host-pathogen interaction
Virulence factors of C. albicans
▶
Hyphal formation and pseudohyphal invasion of epithelium
Adherence proteins and biofilm formation
Secreted aspartyl proteases damaging mucosal barrier
Host susceptibility factors
▶
Elevated vaginal glycogen provides substrate for Candida growth
Estrogen increases glycogen deposition explaining premenstrual flare and pregnancy risk
Disrupted Lactobacillus flora after antibiotic exposure
Immune response
▶
Th17 pathway and IL-17 critical for mucosal defense
Genetic variants in IL-17 pathway associated with RVVC susceptibility
Impaired neutrophil and T-cell function in HIV and diabetes
Non-albicans pathophysiology
▶
C. glabrata lacks true hyphae and relies on yeast phase
Biofilm formation contributes to treatment resistance
Intrinsic reduced azole susceptibility via efflux pump mechanisms
Therapeutic Considerations
Azole antifungal mechanisms
▶
Ergosterol synthesis inhibition via lanosterol 14-alpha-demethylase blockade
▶
Disrupts fungal cell membrane integrity
Fluconazole is the most widely used triazole
Azole resistance mechanisms
▶
Overexpression of efflux pumps (CDR1, CDR2, MDR1)
ERG11 gene mutations reducing azole binding affinity
Biofilm formation reducing drug penetration
Novel mechanism agents
▶
Ibrexafungerp: glucan synthase inhibitor with activity against azole-resistant strains
Oteseconazole: highly selective fungal CYP51 inhibitor with minimal human CYP450 interaction
Treatment duration and recurrence
▶
Single-dose fluconazole achieves mycologic cure in approximately 70% to 80% at 1 month
Longer treatment courses increase mycologic cure rates
Maintenance suppression reduces RVVC recurrence rate by approximately 90% during active therapy
Relapse after cessation of maintenance in 30% to 50% of cases within 6 months
Microbiome-based considerations
▶
Lactobacillus dominance protective against Candida overgrowth
Probiotic supplementation has not shown consistent benefit in clinical trials
Boric acid mechanism
▶
Fungistatic effect via inhibition of cell membrane enzyme activity
Efficacy against non-albicans species and azole-refractory C. albicans
Patient Discharge Instructions
copy discharge instructions
Copy
Vaginal yeast infection home care instructions
▶
Take all medication exactly as prescribed
▶
If using vaginal cream or suppository, insert as directed each night for the full course
If given a single fluconazole tablet, take it with food or water
Do not stop treatment early even if symptoms improve
Managing symptoms while treatment takes effect
▶
Cool water rinse or sitz bath to relieve vulvar itching and burning
Wear loose, breathable cotton underwear
Avoid tight-fitting clothing and synthetic fabrics
Pat the area dry gently after bathing; avoid excessive moisture
What to avoid during treatment
▶
Avoid sexual activity until symptoms fully resolve and treatment is complete
Vaginal creams can weaken latex condoms and diaphragms — use alternative contraception
Avoid douching or scented vaginal products
Avoid perfumed soaps, bubble baths, or hygiene sprays in the genital area
Reducing future risk
▶
If symptoms developed after antibiotic use, speak to your doctor about fluconazole 150 mg at the time of future antibiotic courses
If you have diabetes, maintaining good blood sugar control reduces yeast infection risk
Wipe front to back after using the toilet
Return to the emergency department if you experience
▶
Fever or chills
Pelvic pain or lower abdominal pain
Pain during intercourse or with urination that worsens
Symptoms not improving after completing the full course of treatment
Symptoms returning within 2 months of treatment
Vaginal discharge that changes character (becomes frothy or develops a fishy odor)
Rash, blistering, or ulcers on the vulva or vagina
Signs of allergic reaction (rash, difficulty breathing, swelling of face or throat)
Follow-up care
▶
See your family doctor or gynecologist if this is a recurring problem (4 or more episodes per year)
A culture test may be needed to identify the exact yeast species and guide treatment
Inform your doctor if this is your third or more episode this year
References
Guidelines and key sources
Primary clinical guidelines
▶
CDC Sexually Transmitted Infections Treatment Guidelines 2021 — VVC section
▶
Classification of uncomplicated vs complicated VVC
First-line and alternative treatment regimens
IDSA Clinical Practice Guidelines for Candidiasis (Pappas et al.)
▶
Covers VVC treatment including RVVC management
Class recommendations for fluconazole maintenance therapy
American Academy of Family Physicians (AAFP) Vaginitis Diagnosis and Treatment 2025
▶
Diagnostic algorithm for vaginitis evaluation
Differential diagnosis framework
Evidence references
▶
Sobel JD. Vulvovaginal candidosis. Lancet 2007 — foundational epidemiology and pathophysiology
Pappas PG et al. Clinical Practice Guideline for the Management of Candidiasis — IDSA
Workowski KA et al. Sexually Transmitted Infections Treatment Guidelines — CDC MMWR 2021
Blostein F et al. Recurrent vulvovaginal candidiasis — Annals of Epidemiology 2017
FDA approvals and drug references
▶
FDA approval of oteseconazole (Vivjoa) May 2022 for RVVC
FDA approval of ibrexafungerp (Brexafemme) June 2021
ICD-10 and coding references
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ICD-10 B37.3 — Candidiasis of vulva and vagina
ICD-10 N76.0 — Acute vaginitis (bacterial vaginosis)
ICD-10 A59.01 — Trichomonal vulvovaginitis
SNOMED CT concept: vulvovaginal candidiasis disorder
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Vaginitis (Candidal)